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Case of the Week

51 year old male presented with acute inferior wall MI.

Right femoral approach. RCA could not be directly engaged. Right sinus shot also did not reveal RCA.

Repeated attempts with JR could not catheterize the RCA. With Tiger diagnostic catheter, finally, RCA was seen arising from aortic root high above the right sinus.

Through this catheter, a 300 cm wire was inserted and the RCA lesion was crossed.

Keeping the wire in the RCA, the diagnostic catheter was carefully taken out.

Now, a 6F JR 3.5 guide was carefully taken over the wire and RCA was engaged.

But on passing export aspiration catheter, the guide got disengaged and the wire came out.

RCA was again engaged with Tiger diagnostic catheter, 300 cm wire was used to wire the lesion and the catheter was taken out. This time, 5F JR 3.5 guide was used to engage the RCA.

The lesion was dilated with a 2 x 12 balloon.

It was stented with 3.5 x 32 mm DES with final good result. Since thrombus aspiration was not done, after stenting, there was embolic occlusion of distal PDA. This was left as such. ST resolved and patient was pain free. He made an uneventful recovery.

In this case, the RCA was having an anomalous origin from above the right sinus, as shown by selective injection with Tiger diagnostic. With available guides, the RCA could not be hooked. Hence, with Tiger diagnostic, the RCA was wired and catheter exchange was done to place a guide.

Anomalous culprit vessel in acute ST elevation MI challenges the operator. It increases procedure time and dye usage. A variety of guides may need to be used to find the optimal guide. It only a diagnostic catheter can engage the lesion, it may be exchanged to a guide over a wire.

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